Management Information System (MIS) of the Integrated
Community Case Management (iCCM) of common childhood
illnesses of the L10K Project
The Last 10 Kilometers Project
JSI Research & Training, Inc.
Addis Ababa, Ethiopia
December 2012
2
The Last Ten Kilometers (L10K): What it takes to Improve Health Outcomes in Rural Ethiopia is
implemented by JSI Research & Training Institute, Inc., with grants from the Bill & Melinda Gates
Foundation, UNICEF and USAID. The program covers about 25 million peoples in 229 woredas (i.e.,
districts) in Amhara, Oromia, Tigray, and the Southern Nations, Nationalities and Peoples’ (SNNP)
regions. The program strengthens the bridge between households and the primary health care unit
(PHCU)—the basic health service delivery structure of rural Ethiopia—with the aim to increase demand,
access and utilization of high impact reproductive, maternal, newborn and child health interventions to
contribute towards achieving child and maternal health related Millennium Development Goals 4 and 5.
(i.e., decrease child and maternal mortality rates, respectively). The L10K platform supports 12 Civil
Society Organizations (i.e., L10K grantees) to implement community-based strategies to enhance the
interactions among frontline health workers (i.e., mainly health extension workers [HEWs] and the health
development army [HDA] members), households, and communities to achieve more, better, cost-effective
and equitable MNCH services provided by the PHCUs.
Recommendation Citation: Keller, Brett, Agazi Ameha and Ali Karim. 2012. Management Information
System (MIS) of the Integrated Community Case Management (iCCM) of common childhood illnesses of
the L10K Project. The Last Ten Kilometers (L10K) Project, JSI Research & Training Institute, Inc.,
Addis Ababa, Ethiopia.
Abstract: L10K is supporting the Government of Ethiopia’s scale-up of integrated Community Case
Management (iCCM) of common childhood illnesses by incorporating the strategy with the health
extension program (HEP). To monitor and evaluate iCCM in terms of its access, availability, quality and
performance, L10K established a management information system (MIS), designed by UNICEF. This
document outlines the iCCM Monitoring & Evaluation (M&E) framework of L10K and its
implementation.
Contact information:
The Last Ten Kilometers Project, JSI Research & Training Institute, Inc., PO Box 13898, Addis Ababa, Ethiopia
Phone: +251-116620066; Fax: +251-116630919, Email: [email protected]; Website: www.l10k.jsi.com
3
Contents
Acronyms ...................................................................................................................................................... 4
Introduction ................................................................................................................................................... 5
Overview of L10K/iCCM management structure ......................................................................................... 5
Monitoring and evaluation framework ......................................................................................................... 6
Sources of data .............................................................................................................................................. 7
Training reports ......................................................................................................................................... 7
HEW registers ........................................................................................................................................... 8
Supportive supervision .............................................................................................................................. 8
Selection for SS visits ........................................................................................................................... 9
Forms for SS data collection ................................................................................................................. 9
Feedback during SS ............................................................................................................................ 10
Performance Review and Clinical Mentoring Meetings ............................................................................. 10
Other routine monitoring systems ............................................................................................................... 11
Data compilation and use ............................................................................................................................ 11
Quarterly progress report to UNICEF ..................................................................................................... 12
Regional coordination meetings.............................................................................................................. 14
Feedback to woreda and community levels ............................................................................................ 15
Conclusion .................................................................................................................................................. 15
Appendix 1: Map of L10K and iCCM intervention areas ........................................................................... 16
Appendix 2: Photographs ............................................................................................................................ 17
Appendix 3: Form C ................................................................................................................................... 18
Appendix 4: Form D ................................................................................................................................... 26
4
Acronyms
CSOs Civil Society Organizations
FMoH Federal Ministry of Health
GoE Government of Ethiopia
HDA Health Development Army
HEP Health Extension Program
HEW Health Extension Worker
HC Health Center
HMIS Health Management Information System
HP Health Post
iCCM Integrated Community Case Management
IMNCI Integrated Management of Neonatal and Childhood Illness
IR Intermediate Result
JSI JSI Research & Training Institute, Inc.
L10K Last 10 Kilometers
MDG Millennium Development Goal
M&E Monitoring and Evaluation
MUAC Mid-Upper Arm Circumference
ORS Oral Rehydration Solution
ORT Oral Rehydration Therapy
PHCU Primary Health Care Unit
PRCMM Performance Review and Clinical Mentoring Meeting
RHB Regional Health Bureau
RMNCH Reproductive, Maternal, Newborn, and Child Health
SNNPR Southern Nations, Nationalities, and Peoples’ Region
SS Supportive Supervision
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
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Introduction
The 2011 Ethiopian Demographic and Health Survey (EDHS 2011) indicates that the under-five mortality
rate (U5MR) has been reducing over the past decade and is currently 88 deaths per 1,000 live births.
However, the target for country’s Millennium Development Goal (MDG) 4 is to reduce U5MR to 67
deaths per 1,000 live births by 2015. To accelerate progress towards MDG 4, the Government of Ethiopia
(GoE) incorporated the integrated community case management (iCCM) of common childhood illnesses
with its health extension program (HEP) in Amhara, Oromia, Southern Nation, Nationalities, and
Peoples’ (SNNP) and Tigray Regions covering more than 600 woredas (i.e., administrative districts, each
with about 100,000 peoples). This entailed training more than 12,000 health extension workers (HEWs)
and 2,400 HEW supervisors on iCCM and monitoring and evaluating the quality and performance of
HEWs implementing iCCM. Since 2010, L10K has been supporting the GoE to scale-up iCCM. With
funds from UNICEF and USAID, L10K is now supporting the scale-up of iCCM in 198 woredas.
The iCCM program has several objectives, which are as follows:
Objective 1: Build the skills of HEWs to correctly assess, classify and manage common
childhood illnesses.
Objective 2: Build the skills of HEW supervisors and Woreda Health Office experts to
properly mentor, supervise and coach HEWs on the management of sick children.
Objective 3: Support regular and continuous follow-up, progress reviews, refresher training
and supportive supervision to ensure quality service for sick children as per the integrated
management of childhood illness (IMNCI) guidelines.
Objective 4: Ensure uninterrupted supply of essential drugs and supplies for iCCM at Health
Posts (HPs).
Objective 5: Health development army (HDA) members oriented about iCCM to conduct
active surveillance of cases and refer for treatment.
Objective 6: Establish a mechanism of regular and continuous monitoring & evaluation
(M&E) of iCCM.
To achieve these objectives, the national iCCM activities included forums to develop
implementation guidelines; training of trainers; orientation meetings; learning visits; and regular ongoing
supportive supervision. To monitor and evaluate the scale-up of the iCCM, L10K established a
management information system (MIS) that was designed by UNICEF. The MIS includes a database of
all HEWs and their supervisors who were trained and the quality and performance of the HEWs on
iCCM. For the latter, L10K staff members regularly perform supportive supervision, performance review
meetings and clinical mentoring meetings during which time they extract data from the iCCM registers
maintained by the HEWs. The data are then aggregated, analyzed and feedback is provided to the HEWs
and reported to UNICEF and USAID. This document outlines the iCCM M&E framework of L10K and
its implementation.
Overview of L10K/iCCM management structure
The organizational structure of the L10K/iCCM is diagrammed in Figure 1. The strategic planning,
coordination, implementation, and M&E of iCCM is done by the technical staff at central office located in
6
Addis Ababa and the four regional offices. Approximately 17 Clinical Officers, each responsible for
providing supportive supervision to the HEWs in 10 to 15 woredas, assess the quality of iCCM of
childhood illnesses, collect performance reports, and provide clinical mentoring and feedback.
Figure 1. iCCM Organizational Structure
Monitoring and evaluation framework
The M&E system for the 113 woredas where L10K is implementing iCCM follows the applicable
sections of the national framework described by UNICEF in its iCCM monitoring and evaluation plan1.
The M&E framework is outlined in Figure 2. Figure 2 first lists the processes involved in iCCM,
including those that improve access and availability, quality, demand, and policy, along with other and
cross-cutting process. These processes in turn affect the intermediate results (IRs): 1) improved
access/availability; 2) improved quality; 3) improved demand; and 4) enabled policy. These IRs together
help achieve the two objectives: 1) use of interventions improved, and 2) health system strengthened
(health management information system [HMIS], logistics, and supportive supervision). The
strengthening of the health system also helps improve the use of interventions. Together the improved use
of interventions and the strengthening of the health system result in the ultimate goal of improving
mortality and morbidity. A variety of external factors (e.g., national policies, donor commitments) may
affect this framework at all levels, i.e. the processes, intermediate results, objectives, and goals.
1 UNICEF’s “iCCM monitoring and evaluation plan.” June 7, 2011
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The iCCM monitoring system is especially concerned with measuring progress on the first three
IRs, specifically, 1) improved access and availability, 2) improved quality, and 3) improved demand.
Measuring these intermediate results is important because improvements in them will result in
improvements in the two strategic objectives (use of iCCM interventions and strengthening of the health
system), which in turn will result in improvements in child mortality and morbidity, the ultimate goal of
iCCM.
Figure 2. UNICEF iCCM Monitoring and Evaluation Framework2
Sources of data
The major data sources of the iCCM MIS are training reports, and the iCCM registers maintained by the
HEWs.
Training reports
The initial training for HEWs was a six day course led by specially trained implementers. HEW
supervisors receive a seven day initial training course, which contains the material covered in the HEW
training, plus additional training on supportive supervision. Trainings are documented using Forms A1,
A2, and B, described below.
Data from the HEW trainings and HEW supervisor trainings is collected using the following forms:
2 From UNICEF’s “iCCM monitoring and evaluation plan.” June 7, 2011.
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Form A1: iCCM training report for HEWs. One copy of this form is completed for each
training session for HEWs. Data elements recorded include the date, location, and other
identifying information about the training, a list of facilitators, a list of HEWs trained, the number
of cases seen in clinical session, the clinical signs and classifications seen during the course,
scores for pre-tests and post-tests, course evaluations, a list of HEWs and health posts that
received a kit of iCCM materials, and feedback from training coordinators.
Form A2: iCCM training for HEW supervisors. One copy of this form is completed for each
training session for HEW supervisors. Data recorded includes all of the elements described above
for Form A1, except for the list of HEWs and HPs that received a kit of iCCM materials.
Form B: Checklist for iCCM training quality assessment. This checklist is completed after
each training for HEWs and HEW supervisors by the training supervisors. It includes ratings for
the quality of planning and preparation, the implementation of the training, and the overall quality
of the training.
Copies of forms A1, A2, and B are included in the appendices.
HEW registers
HEWs keep two health registers at the health post: one for children aged 2-59 months and one for
children aged 0-2 months. The registers serve as a tool for appropriately managing childhood illness
cases; and provide data for program monitoring. The HEWs complete these registration books as they see
patients. For each child the register records the following data: name, age, sex, weight, temperature,
child’s problems, and an assessment of symptoms (including couch, diarrhea, fever, ear problems,
malnutrition, anemia, HIV status, immunization and vitamin A status, and feeding habits). Based on the
recorded symptoms the HEW classifies the child’s illness and records it. Based on the classification the
treatment and advice is given to the child’s caretaker and recorded. After conducting the recommended
follow-up of the cases by the HEW the findings are also recorded. The data from these hard-copy
registers is examined and data are extracted through two processes; supportive supervision and
performance review and clinical mentoring meetings.
Supportive supervision
Health center staff and iCCM Clinical Officers regularly visit rural health posts to provide supportive
supervision (SS) to the HEWs. These visits focus on documenting the quality of treatment, availability of
supplies, and knowledge of HEWs. The data collected from iCCM registers during SS is recorded on
Form C/Cb, described in more detail below. These forms are then inputted into a database and analyzed
by regional and national iCCM offices on a quarterly basis.
A single SS visit typically takes a full work day, due to the need to travel to a HP and spend two
to three hours at the health post talking with the HEW. Travel to remote health posts can be challenging
for iCCM staff, especially during rainy season. While some woredas are very close the regional offices,
others are extremely remote: for example, in Tigray some woredas are more than 1,000 km from the
regional capital, and one health post is 300 kilometers away from the center of its woreda. Most SS
activities are conducted by the iCCM Clinical Officers, whereas in a few remote areas, some staff
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members of Bill & Melinda Gates Foundation funded L10K grantee organizations were trained to conduct
SS visits as well; this is the case in 60 out of a total of 276 health posts in Tigray.
The criteria for accurately treating patients are strict: for instance, in one case observed in the
preparation of this document a child with severe pneumonia was appropriately referred to the health
center for severe pneumonia; the child subsequently received antibiotics at the health center and
recovered fully. However, since the HEW did not also give the child the required pre-referral dose of
antibiotic at the health post level this case was counted as being improperly treated.
Selection for SS visits
The first follow-up visit was completed six weeks after the initial training. After the initial follow-up
visit, health center staff members visit each health post at least once per quarter, whereas the target for
iCCM staff is to visit 25% of health posts in their region per quarter.
The Regional Coordinators prioritize which health posts to visit using prior monitoring data,
prioritizing first the posts that have gone the longest without an SS visit, and then prioritizing by HEW
performance during the last SS. Regional Coordinators generally do not have difficulty prioritizing health
posts, as problems often became apparent due to difficulties in the training sessions, poor participation in
the review meetings, or poor performance at prior supportive supervision visits.
The iCCM Clinical Officers conducting SS visits examine the previous SS forms before visiting
the health post to identify past problem areas; these are transferred to the new form and addressed as
possible.
Forms for SS data collection
Form C is completed during the first follow-up supportive supervision visit to a HEW at their HP. Form
Cb collects the same information, but is used for subsequent follow-up supportive supervision visits. Both
forms include identifying information for the HEW and health post/kebele, key issues from the previous
visit (if applicable), the HEW quality review, data review, supply review, and knowledge review, and key
findings/weaknesses that need to be improved. The review section of Forms C/Cb are described further
below:
HEW quality review: This section of Form C/Cb requires the supervisor to select the two most
recent cases for each classification – pneumonia, severe pneumonia malaria, very severe febrile
diseases or complicated measles, diarrhea with no or some dehydration, severe dehydration or
dysentery, severe uncomplicated malnutrition, and severe complicated malnutrition – from each
of the two HEW registration books: one for children aged two months to five years and one for
infants aged zero to two months. The supervisor conducting the SS visit records whether the data
in the HEW register support the assessment, treatment, and follow-up recorded in the register.
The forms also include information about the outcomes of the recorded cases, and whether there
were children checked for well child care during the reporting period. If clients visit the health
posts during a supportive supervision visit, the supervisors conducting the visit then directly
observe the care the clients receive, offering praise and critical feedback as necessary.
Data review: This section of Form C/Cb includes a count of the number of children managed and
reported by the HEW in the last calendar month, obtained by examining the HMIS reporting
form.
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Supply review: This section of Form C/Cb includes a checklist of essential job aids in place on
the day of the visit (e.g., chart booklet, registration book for children 2-59 months, registration
book for children 0-2 months, and family health cards) and a checklist of essential functional
equipment on the day of visit (e.g., watch, scale, MUAC tape, thermometers, and newborn
Ambu-bag). This section also includes a checklist of oral drugs and supplies, including their
current availability and stock-outs in the last month, as well as proper drug and supply storage.
The presence of a functional oral rehydration therapy (ORT) corner is also recorded. Current
availability of all supplies on the day of the SS visit is recorded, as well as stock-outs in the last
30 days; if supplies are stocked out for more than seven days, the health post is defined as having
had a stock-out.
Knowledge of HEWs: This section of Form C/Cb includes an assessment of HEW knowledge,
answered while referring to job aids. Questions cover cough, diarrhea, ORS, danger signs, and
essential newborn care actions. While answering the knowledge questions, HEWs are encouraged
to consult their chart and not to memorize things while answering; this tests whether they can
apply the knowledge in practice as they are expected to use the book as they work.
A copy of Form C is included in the appendices.
Feedback during SS
The thorough and representative data collected through SS is the backbone of the iCCM monitoring
process. In addition to being a source of monitoring data, SS visits are an opportunity for HC and iCCM
staff to analyze the performance of HEWs and give both encouragement and critical feedback.
When giving feedback, the iCCM officers try to help the HEW realize the solution for
themselves, rather than lecturing them. For example, if the HEW has a low caseload, the iCCM staff
conducting the supportive supervision would help the HEWs realize that they may need to work with the
HDA more intensively to mobilize the community and stimulate demand. Likewise, with a drug stock-out
the HEWs may want to simply refer clients to the health center to be treated there, whereas they should
call the health center for an updated supply of drugs so as to be able to treat clients closer to home.
The iCCM staff try to promote a friendly, productive relationship with HEWs during health post
visits – this is in fact one of the main tactics of supportive supervision. Punitive measures (such as firing)
and other incentives are not an option, so iCCM staff must strive to motivate HEWs through strong
interpersonal relationships.
Performance Review and Clinical Mentoring Meetings
Performance review and clinical mentoring meetings (PRCMM) are three-day meetings conducted every
six months at the woreda level. PRCMMs have been conducted in all 113 woredas and the second phase
of review meetings is currently under way. These meetings are an important opportunity to both
encourage the HEWs and to identify potential problems. In contrast to the supportive supervision visits,
where the focus is on the quality of care for a limited number of cases for the selected posts that are
visited, the PRCMM is an opportunity to collect data on all cases managed by HEWs in the woreda
during a specific time period. The PRCMMs are thus essential for monitoring the overall performance of
iCCM.
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At the review meetings, Regional Coordinators and Clinical Officers examine HEW registration
books for sick child (SC) and sick young infant (SYI) to extract and aggregate data program performance
monitoring. For each of common childhood illnesses covered by iCCM the major program performance
indicators that were captured were caseload, consistency in classification, treatment, and follow-up within
cases against the protocol.
The program performance monitoring based on PRCMMs provide information on which health
posts and woredas are doing better or worse, and these qualitative impressions are some of the most
valuable monitoring tools for the regional office staff because they help them quickly assess which areas
need more assistance.
Some PRCMMs have been delayed because of other priorities at the woreda level (i.e., the
regional health bureaus [RHBs] were not prioritizing the scheduling of iCCM review meetings over other
activities). The regional manager must thus works closely with the RHBs and woreda health officials to
schedule the review meetings.
Other routine monitoring systems
In addition to the iCCM reporting system, HEWs also report cases through the GoE’s Health
Management Information System (HMIS). HEWs also report specific notifiable diseases that might cause
local epidemics through a separate disease surveillance system (via phone).
Data compilation and use
The HP/kebele-level data are kept using paper tally sheets and register books. These data are then
aggregated according to the process shown in Figure 3.
The Clinical Officers input each of the forms collected (Forms C and Cb) using a custom-
designed EpiInfo interface. Inputting the forms using EpiInfo improves data quality by taking advantage
of the program’s sophisticated skip patterns and checks for internal consistency.
The regional manager then checks to ensure that all woredas that have had supportive supervision
during that quarter are included in the data. The regional manager then sends this combined quarterly
database to the L10K Monitoring and Evaluation and Research (M&E&R) Specialist in Addis Ababa.
The M&E&R Specialist checks the data for completeness, and then conducts initial data analysis,
sometimes with the assistance of the M&E&R Senior Advisor for L10K and iCCM. After two to three
weeks, feedback is sent back to the four Regional Coordinators, who then communicate the findings and
recommendations to the Clinical Officers.
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Figure 3. iCCM data collection and storage
Quarterly progress report to UNICEF
The M&E&R Specialist writes a quarterly progress report that is sent to UNICEF. This report typically
includes data in the form of a number of tables (represented by dummy tables 1-5 below), along with
narrative text describing iCCM accomplishments and challenges during the quarter. The quarterly
progress report focuses on regional and national analysis and does not break results down to the health
post or woreda level. The following tables are included in the quarterly progress report:
Table 1: Total number of health workers who received IMCI training during this
quarter, by region
Region No. of
sessions
Total No. of Health
Workers targeted
No. of Health Workers
trained this quarter
%
covered
Amhara
Oromia
SNNP
Tigray
Total
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Table 2: Total number of health posts visited for start-up and 2nd round
supportive supervision visits during this quarter, by region
Region
No. of HPs visited
for follow-up this
quarter
No. of Health Workers
trained this quarter
Coverage (%)
achieved in
targeted HPs
Start-
up
2nd
round
Start-
up
2nd
round
3rd
round
Start-
up
2nd
round
Amhara
Oromia
SNNP
Tigray
Total
Table 3: Total number of woredas and health posts that received a 1st and 2nd round
PRCMM during this quarter, by region
Region
1st round PRCMM 2nd round PRCMM
No. Woredas
covered for
reporting period
No. of woredas
covered to date
No. of Woredas
covered for
reporting period
No. of woredas
covered to date
Amhara
Oromia
SNNP
Tigray
Total
Table 4: Total number of woredas and health posts covered with a 2nd round PRCMM and
number of sick children under the age of five years managed by HEWs, by sex and age
Region No of
Woredas
No of
HPs
Total number of cases (age
2-59 months)
Total number of cases (age 0-2
months)
Male Female Total Male Female Total
Amhara
Oromia
SNNP
Tigray
Total
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Table 5: Total number and type of cases (among sick children 2-59 months of age)
assessed and treated by HEWs (data collected during PRCMM), by region
Description of data SC cases (2-59 months)
Amhara Oromia SNNP Tigray Total
Number of HP
Pneumonia
P/Sever/S diarrhea/Dysentery
Diarrhea(some)
Diarrhea(no)
Malaria
Severe Uncomplicated
Malnutrition
Severe Complicated Malnutrition
Measles with eye complication
Measles
Rx with Cotrimoxazole
Rx with ORS
Rx with Coartem
Rx with Chloroquine
Regional coordination meetings
In addition to activities conducted by iCCM staff, interactions with other organizations are essential for
the success of monitoring activities. The iCCM regional offices participate in a monthly meeting with the
RHB as part of the Child Survival Technical Working Group, a body that includes the RHB, L10K/
iCCM, and other NGOs that do related work. During these meetings, representatives from these
organizations discuss achievements related to child survival, along with difficulties that need to be
overcome. Thus these meetings serve as a venue for distributing results of the iCCM monitoring system,
but also provide valuable qualitative monitoring information on the program and regional health activities
as a whole.
During these meetings, iCCM shares some of the routine data in which the RHB is most
interested, such as caseload and service utilization information. Newly identified problems, such as a
particular health post not being open, are raised at the meetings as well. The data from the iCCM
monitoring system are thus useful at these meetings.
Form D, the “iCCM National and Regional Technical Working Group Meeting Tracking Form”
is completed during each meeting. This form records the date, venue, participating partners, agenda points
discussed, and main decisions or agreements arrived at for each meeting of national and regional technical
working groups. A copy of Form D is included in the appendices.
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Feedback to woreda and community levels While iCCM staff members give general updates to the RHB, they often discuss more specific problems
with woreda level staff. The Regional Coordinators and Clinical Officers work directly with the health
centers and woreda-level health staff, as these officials are closer the ground and thus more able to deal
with problems that arise at the health post and community level.
Conclusion
Establishing a mechanism for continuous monitoring and evaluation is one of the objectives of iCCM.
UNICEF’s M&E framework for iCCM calls for tracking several Intermediate Results, including access,
availability and quality of case management and provides feedback, accordingly. The HMIS described in
this document serves as the backbone of the iCCM M&E framework and contributes to fulfill these
objectives.
The iCCM registers are designed to assist the HEWs to follow the iCCM protocol for
classification, treatment and follow-up of diseases. The HMIS draws data from HEW and HEW
supervisor trainings and from HEW registers, through processes that include SS and PRCMM. The data
are entered into databases from a number of standardized forms, and this data is then analyzed to create
quarterly progress reports for UNICEF and to give feedback to the regional iCCM offices. The awareness
of iCCM progress and challenges created by this continuous data monitoring helps L10K/iCCM staff
ensure that the program achieves its objectives.
L10K is now expanding implementation of iCCM to a total of 198woredas. As L10K/iCCM
expands coverage to these additional woredas, the HMIS will be essential to its success. Rigorous
implementation of iCCM—reinforced by routine program monitoring—is bringing proven case
management techniques for childhood illnesses to the kebele level in Ethiopia, accelerating Ethiopia’s
progress towards meeting MDG 4.
16
Appendix 1: Map of L10K and iCCM intervention areas
17
Appendix 2: Photographs
Photo 1: Tigray Regional Coordinator and a Health Extension Worker review one of the treatment
registration books.
Photo 2: Tigray regional iCCM staff members and Health Extension Worker review the health post’s
supplies of materials.
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Appendix 3: Form C
Implementing NGO partner___________________
Form C: ICCM Supportive Supervision/ Follow up checklist
I. Identification
Region__________ Zone: ____________Woreda:_____________ Kebele/H. Post: ________________
Kebele’s total # of population; _______; Total # <5 population_________
Name of supervising health centre: _______________
Name of HEW in charge: __________________date of visit (dd /mm/yyyy) _________ Lead
supervisor’s name: __________________Responsibility ____________ Organization_______________
Period covered since last visit: ____weeks.
Direct Case Observation made: Yes__ No ___Number of sick <5 observed: ____; SC*___SYI**__
ICCM registration book reviewed: Yes __No __# of sick <5 whose case has been reviewed __; SC__SYI__
II. HEW case management performance (quality of care) assessment of the last 10 Sick children
Main symptoms found
in sick child 2 month
to 5 year
#cl
ass
ific
ati
on
s
seen
=A
Agreement between case management tasks
Assess and Classify =
B
Classify and treat
(DSD)*** = C
Classify & Stated f/ up date
=D
#Agree #Agree # agree
Cough/difficult
breathing
Fever
Diarrhea
Malnutrition
Total classifications
seen in SC
Age below 2 months
Possible serious
bacterial infection/
severe disease
Total classifications
seen in SYI
*SC= sick child; **SYI= sick young infant; ***DSD= Correct Dose, Schedule and Duration.
Guide on how to fill the grid A= Tally the # of classifications given by the HEW against each main symptom found, assessed, and checked
among the reviewed < underfive children
B= Tally the # of classifications that agree with assessment against each main symptom found and checked among
the reviewed < underfive children.
C= Tally the # of classifications that agree with treatment against each main symptom found and checked among the
reviewed < underfive children.
D= Tally the # classifications that agree with the follow up given by the HEW (when the sick <5 has more than one
health problem take the shortest date that comes first and assume as if that child has received f/up care for the
rest)
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IIa. Children with severe classifications and parent’s compliance to referral recommendation
(From iCCM register review)
# of children with
severe classifications (as
given by HEW)
# recommended
with referral
# complied to referral
recommendation
Remarks
IIb. Children with none severe classifications and parent’s compliance to follow up within treatment period
(From iCCM register review of follow up outcomes)
# of children with non-
severe classifications (as
given by HEW)
# recommended
with referral
# complied to recommendation Remarks
IIc. Treatment outcome of children managed by HEW in the health post/community in the reporting period
(From iCCM register review of follow up outcomes)
Total # managed and
received f/up care
outcomes
# The
same
# Improved # Worsened Died Unknown (didn’t receive
f/up care or outcome not
recorded
Remarks
IId. Children checked for well child care in the reporting period (register review)
Age of sick child Total # Checked for
Immunization
checked for vitamin
A
Checked for
deworming
Remarks
> 6 months Yes No
<24 months Yes No
>24 months Yes No
IIe. # of Children managed for classification in the reporting period (register review)
No Classification # F # M remark
1 Pneumonia
2 Diarrhea
3 Malaria
4 Measles
Measles with eye/mouth complication
5 Severe uncomplicated malnutrition
6 Severe complicated malnutrition
7 All children with severe classification seen
8 All episodes of classifications seen
Sick young infant
1 Very sever disease
2 Local bacterial infection
3 All episodes of classifications seen
20
III Immunization coverage Plan performance chart; EFY____________
Antigen Q
uarter I
Quarter II Quarter III Quarter IV Annual Remarks
# % # % # % # % # %
Pentavalent 3
Measles
TT2+ Pregnant
IV. Logistics
IVa. Essential Job aids in place (in use) on the day of visit (Put a √ mark)
Item Yes No Remark
1 Chart booklet
2 IMNCI Registration books
3 Family health card
4 OTP card (where service is available)
IVb. Essential Equipments on the day of visit
Item Yes No Remark
1 Watch with second’s arm
2 Weighing scale - Baby lying or Salter
scale with bowel
3 MUAC tape
4 Thermometer
5 Newborn Ambu-bag
IVc. Drugs and supplies (Put a √ mark)
No Oral drugs and supplies Last date
procured
Available on
day of visit (√)
Out of stock in the
last one month (√) Remarks
Dd/mm/yyyy Yes No Yes No
1 ORS
2 Cotrimoxazole
3 Artemether Lumefentrine (Coartem)
4 RUTF (Plumpy nut or BP100)
-eligible health post
5 Amoxicillin for OTP
6 Mebendazole / Albendazole
7 Vitamin A
8 Zinc tablets
9 Paracetamol
10 TTC eye ointment
11 Vitamin K
12 2cc syringe and needle
13 RDT reagent
21
VId: Drugs and supplies stored in appropriate manner Yes No
Appropriate manner includes all of the following:
1) Storage is free from rodents or insects
2) Protected from sunlight
3) Sufficient space for the quantity
4) Dry space and free from flooding
V. ORT corner
(Put √ mark)
VI. Has the HP/HEW received supervisory visit in the last 3 months? 1. Yes b. No
VII. How are you working with VCHW to strengthen the implementation of iCCM?
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
VIII. Assessment of Knowledge –tell HEW to refer her job aids to answer the questions
Cough or difficult breathing
1. What is the correct breathing per minute cut off for the following? a) Infant less than 2 month ______ (60/min) correct: Y/N_____
b) Child 2-12 months ______ (50/min) correct: Y/N_____
c) Child 12-59 months ______ (40/min) correct: Y/N_____
2. Could you tell the correct doses of co-trimoxazole for?
a) Sick child weighing 7kg Y/N____
b) Sick child age 12 to 59 months Y/N____
Diarrhea
3. What are the 4 rules of home management for a child with diarrhea (plan A? (Do not prompt) a. Give extra fluid (breastfeed more frequently for EBF infant) Y/N _____
b. Continue feeding Y/N _____
c. Give zinc Y/N _____
d. When to return Y/N _____
4. Could you tell the correct amount of ORS for a child with some dehydration?
a) Sick child weighing 10 kg Y/N____
b) Sick child age 6 months Y/N____
5. What are the General Danger Signs (GDS) in a sick child 2 months up to 5 years?
6. What are the signs of possible serious bacterial infection (PSBI)/ severe disease in the sick
young infant birth to 2 months?
Service Yes No
ORT corner available (at least; a measuring jug,2cups, spoon, clean water, ORS)
ORT corner functional (ORS solution given according to Plan B-registered)
22
(Mark all that are noted, without prompting)
7.
Mention the Essential Newborn Care actions (Put √ mark)
IX. Summarize the findings and secure agreement from the HEWs IX a. Main Positive Findings (strengths):
1. _______________________________________________________
2. _______________________________________________________
3. _______________________________________________________
4. _______________________________________________________
GDS 2 months to 5 years
Y/N
PSBI/severe disease signs under 2
months
Y/N
Lethargic or unconscious
Not feeding well
Convulsions
Unable to drink or breastfeed Fast Breathing
Severe chest indrawing
History Convulsions Grunting
Fever or low body temperature
Persistent vomiting Movement only when stimulated
No movement even when
stimulated
Actions
1 Deliver baby on to mother’s abdomen or into her arms Yes No
2 Dry baby’s body with dry towel; wipe eyes; wrap with another dry one and cover head
3 Assess breathing, if not breathing or gasping or if breathing is <30 breaths per minute, then
resuscitate.
4 Tie the cord two finger from abdomen and another tie two fingers from the 1st one. Cut
between the two ties and separate the baby from the placenta.
5 Place the baby in skin-to skin contact with his mother and on the breast to initiate breastfeeding
6 Apply Tetracycline eye ointment once to the newborn’s eyes
7 Give Vitamin K, 1mg IM on anterior mid thigh
8 Weigh baby properly
Advice mother to delay bathing of the baby for 24 hours after birth
Provide 4 postnatal visits during at 6-24 hour, 3rd
day, 7th day and 6th
week
23
IX b. Findings that need to be improved (weaknesses):
s. n. Major Findings that need to be improved Action taken
1
2
3
4
IX c. Further suggestions if any:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____
____________________________________________________________________
Annex: Sick child and sick young infant record forms for direct case observation
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEAR Name: ___________________________ Age: ______ Sex_______ Weight: _______ Temperature: _____°C
ASK: What are the child’s problems? _________________________________________ Initial visit? __Follow-up Visit? ___
ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS
LETHARGIC OR UNCONSCIOUS CONVULSING NOW
General danger signs present Yes__ No__
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes___ No___ For how long? ___ Days Count the breaths in one minute.
____ breaths per minute. Fast breathing? Look for chest indrawing. Look and listen for stridor.
DOES THE CHILD HAVE DIARRHEA? Yes ____ No ___
For how long? __ Days Is there blood in the stool?
Look at the child’s general condition. Is the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
(slowly less than 2 seconds)
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature > 37.5 C or above) Yes___ No___ Malaria Risk: High Low No if low or no malaria risk, then ask: Has the child travelled outside this area during the last one month?
If yes, has he been to a malarious area? For how long has the child had fever? __ Days If more than 7 days, has fever been present every day?
Has child had measles within the last three months?
Look or feel for stiff neck. Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes. Do RDT: Positive Negative__ Not done_
If the child has measles now or within the last 3 months:
Look for mouth ulcers. Look for pus draining from the eye. Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No___ Is there ear pain? Is there ear discharge? If Yes, for how long? ____ Days Look for pus draining from the ear.
THEN CHECK THE SICK CHILD BELOW 6 MONTHS OF AGE FOR MALNUTRITION
Look For visible severe wasting Look for pitting oedema of both feet.
THEN CHECK FOR MALNUTRITION THE SICK CHILD AGE 6
MONTHS AND ABOVE
Measure MUAC MUAC Less than 11cm MUAC 11 cm to <12 cm MUAC >12 cm and above . Check for Pitting oedema of both feet Complication: Pneumonia, watery diarrhoea/dysentery, fever If MUAC <11cm or oedema of both feet and no medical complication do
appetite test: fail/ pass
THEN CHECK FOR ANEMIA Look for palmar pallor: Severe pallor? Some pallor? CHECK FOR POSSIBLE SYMPTOMATIC HIV INFECTION Ask: what is the HIV status of the mother Positive__, Negative__, Unknown___ What is the HIV status of the child Positive__, Negative__, Unknown___
CHECK THE CHILD’S IMMUNIZATION (age<2 year) AND VITAMIN A STATUS Circle immunizations/vitamin A needed today. _______ ______ _______ ________ BCG Pentavalent-1 Pentavalent-2 Pentavalent-3 _____________ __________ ____________ Pneumococcal-1 Pneumococcal-2 Pneumococcal-3 _______ ________ ____ _____ _______ ________ _________ OPV 0 OPV 1 OPV 2 OPV 3 Measles VITAMIN A Mebendazole / Albendazole
RETURN FOR NEXT IMMUNIZATION/ VITAMIN A ON: _______________
(DATE)
ASSESS CHILD’S FEEDING if child has ANEMIA OR MODERATE ACUTE MALNUTRITION or is less than 2 years old. FEEDING PROBLEMS: Do you breastfeed your child? Yes____ No ____
If Yes, how many times in 24 hours? ___times. Do you breastfeed during the night? Yes___ No___. Do you empty one breast before you shift to the other one ? Does the child take any other food or fluids even water? Yes___ No ___
If Yes, what food or fluids? How many times per day? ___times. What do you use to feed the child? If the child has moderate acute malnutrition: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how?
During this illness, has the child’s feeding changed? Yes ____ No ____, if Yes, how? _______________________________
ASSESS FOR OTHER PROBLEMS COUNSEL THE MOTHER ABOUT HER OWN HEALTH
25
MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS Name: __________________________________ Age: ______ Sex:________ Weight: _______ kg Temperature: ____°C ASK: What are the infant’s problems? __________________________________ Initial visit? ___ Follow-up Visit? ___ ASSESS (Circle all signs present) CLASSIFY ASSSESS FOR BIRTH ASPHYXIA (immediately after birth)
Not breathing Is breathing poorly (less than 30 per minute) Gasping
ASSESS FOR BIRTH WEIGHT AND GESTATIONAL AGE (the first Ask gestational age; <32 wks, 32-<37wks, ≥ 37wks
7 days of life) Weigh the baby: <1500g, 1500-<2500g, ≥2500g
CHECK FOR POSSIBLE BACTERIAL INFECTION /SEVERE DISEASE and JAUNDICE
Has the infant had convulsions? Has the infant stopped feeding well?
Count the breaths in one minute. ____breaths per minute Repeat if 60 or more ________ Fast breathing? Look for severe chest indrawing. Look and listen for grunting. Look at umbilicus. Is it red or draining pus? Fever (temperature > 37.5°C or feels hot) or body temperature below
35.5°C (or feels cool) Look for skin pustules. Look at young infant’s movements. Does the infant move only when stimulated?
Does the infant not move even when stimulated? Look for jaundice? Are the palms and soles yellow? Are, skin on the face or eyes yellow? Is age less than 24 hours or more than 14 days
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes _____ No ______
For how long? _______ Days Is there blood in the stools?
Look at the young infant’s general condition: Does the infant move only when stimulated? Does the infant not move even when stimulated? Is the infant restless or irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?
CHECK FOR HIV INFECTION Ask: what is the HIV status of the mother Positive____, Negative_____ , Unknown______
What is the HIV status of the child Positive____, Negative_____, Unknown______
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
Is the infant breastfed? Yes _____ No _____ If Yes, how many times in 24 hours? _____ times Do you empty one breast before switching to the other? Yes ___No__ Do you increase frequency and length of breastfeeding during illness? Yes __No__ Does the infant receive any other foods or drinks, even water? Yes ___ No ____ If Yes, ask for any reason and how often? if yes what do you use to feed the child?
Determine weight for age. Low ___ Not Low ___
If the infant is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is under weight for age AND has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour? - If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. - If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again Is the infant positioned well? To check positioning, look for:
- Infant’s head and body straight Yes ___No ___ - Facing the breast nose against nipple Yes ___No ___ - Infant’s body close to mother's body Yes ___No ___ - Mother supporting the whole body Yes ___No ___
Is the infant able to attach? To check attachment, look for: - Chin touching breast Yes __No __ - Mouth wide open Yes __No __ - Lower lip turned outward Yes __No __ - More areola above than below the mouth Yes __No __
no attachment at all not well attached good attachment
Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling at all not suckling effectively suckling effectively Clear blocked nose if it interferes with breastfeeding Look for ulcers or white patches in the mouth (thrush).
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS Circle immunizations needed today. ______ ______ ______ BCG Pentavalent-1 Pneumococcal-1 ______ ______ OPV 0 OPV 1
Return for next
immunization on: ______________
(Date) ASSESS OTHER PROBLEMS: COUNSEL THE MOTHER ABOUT HER OWN HEALTH
Appendix 4: Form D Form D: ICCM National and Regional Technical Working Group Meeting Tracking Form
No Date Venue Partners participated Main agenda points discussed Main decisions/agreements Remarks
